A nurse is employed at an acute care clinic and is caring for a patient who has been brought in with diabetic ketoacidosis. The patient has a respiratory rate of 36/minute and labored, heart rate of 120 bpm, and blood pressure of 130/86 mmHg. The patients blood glucose level is 260 mg/dL and he is confused and has high ketone levels. In which order should the nurse manage this patients condition?

 

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Correct

- Vital signs, fluid resuscitation, blood glucose levels

- Fluid resuscitation, glucose levels, vital signs

- Glucose levels, vital signs, fluid resuscitation

- Glucose levels, fluid resuscitation, vital signs

Rationale

In an emergency, the nurse's first priority is the primary interventions to maintain a patients airway, breathing, and circulation. This patients breathing is labored and his heart rate is elevated, which is causing distress. These signs must be managed first. Although the glucose level is high and it is important to manage this condition as well, the nurse first must focus on vital signs.

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